Choosing Our Future

By Louis A. Kirby

Over the last several decades medical breakthroughs have raised complex questions which test our ethical standards. On the one hand are the concrete benefits they offer to those suffering from disease or impairment, to their families, and to doctors and researchers with professional, humanitarian, and economic interests in these new procedures. On the other are costs, some concrete, some ethical. These often center on definitions of a human being, and of life and death; on the appropriate relations of means to ends; and on choices among competing values. Ethical consequences are not mere abstractions. Loss of integrity, accommodation to what we instinctively feel is wrong, violations of justice or trust — all of these degrade us as individuals and lower the moral health of the society we live in. Individually we may feel that we have little information and less influence in scientific and technical matters, yet our collective decisions — or lack of decisions — are determining societal standards for years to come. Recently media attention has focused on controversy surrounding fetal stem-cell research, which has divided public opinion almost evenly. A recent editorial in The New Republic ("Only Human," July 30, 2001, p. 8), in which Andrew Sullivan takes a critical position, raises many of the central issues. He begins by examining the claim that blastocysts — the human reproductive cells desired for stem-cell research — are probably not human, and certainly not "beings" any more than are fingernail clippings, which also contain an individual's complete DNA code. But, he asserts, "the fingernail comparison misses something important. A fingernail would not become a mature human being if implanted in a womb. The real question is whether this distinction amounts to a moral difference."

Starting with fundamentals, we might ask, What is it that makes us human? Today many scientists would say that it is our DNA which defines our humanity. Those promoting stem-cell research would also include the entity's stage of development in order to eliminate the unborn, yet Sullivan points out that "the embryo contains exactly the same amount of genetic information as you or I do. We aren't different from it in kind, only different in degree: in age, size, weight, gender"; essentially, each blastocyst is "as unique as any human being who has ever lived or ever will," and "once a blastocyst is killed, the human being coiled inexorably inside is no more." Experimenting on such cells, he concludes, "is to treat human life purely instrumentally. I know of no better description of evil." This is especially true when abandoning the use of human reproductive cells would only slow research, not stop it; other sources of stem cells are available.

Various criteria have been proposed to determine whether an entity possesses human rights and dignity in the context of scientific research. Among these are rationality, self-consciousness, and the ability to feel pain. While such attributes seem to exclude embryos from full human status, they also bring into question other groups such as infants, paraplegics, the mentally ill, and Alzheimer's patients, particularly "those whose mental capacity renders them unable to give meaningful consent." Another frequently proposed criterion is viability, but

If "viability" independent of a mother or others is the criterion, why shouldn't the physically incapacitated or the very old be consigned to medical experimentation? Why not those in comas or on life support? If they're going to die anyway and have no ability to fend for themselves, what's the point of wasting their bodies when they could yield valuable medical insights? Yes, we could wait till they're dead — but they're far more useful to science alive.

Such arguments might appear extreme, but they are far from academic. They relate directly, for example, to organ donation, as an article in the August 13th New Yorker brings out. In "As Good As Dead" Gary Greenberg examines the biological reality of "brain death" — a definition of death adopted after the development of both respirators and transplant technology. In the 1960s it became possible to keep severely injured patients alive on life support systems, and after transplants became a reality doctors realized that such patients are an ideal source for transplant organs. Not coincidentally, a 1968 report by a Harvard Medical School committee, published in the Journal of the American Medical Association, came to the conclusion that "patients whose brains no longer functioned and who had no prospect of recovering were not lingering but were already dead — brain dead" (Greenberg, p. 37). This new standard allowed doctors in good conscience to take such people off respirators, or to remove organs while patients were still on life support in order to avoid tissue changes that are disastrous to transplant success.

The concept of brain death is now thoroughly entrenched in the medical establishment and legally recognized throughout the United States. Nevertheless, many physicians admit that it is a type of legal fiction; that is, brain death occurs, not because of a clear-cut biological event, but because of a social agreement. Most doctors and the pro-transplant community vigorously resist public debate of the subject: they fear any admission that brain-dead patients are in some sense not "fully" dead would discourage organ donation and open an ethical debate "turning transplant into another medical practice — like abortion or fetal stem-cell research — that's bogged down in intractable political wrangling" (p. 41) driven by competing ethical viewpoints. Greenberg considers the pros and cons of presenting organ harvesting to the public as a form of justified, socially condoned euthanasia. Admitting the actual situation, he believes, would increase the number of usable organs recovered by allowing terminally ill patients without traumatic brain injuries to be declared legally "dead" (medically available) at some point while they are still on life support. Doctors could then remove their organs while the heart is still beating, in the process ending the donor's life. Greenberg reflects that

It may be too much to say that the concept of brain death is an outright lie, but it is certainly less than the truth. Like many of technology's sublime achievements, organ transplant, for all its promise, also has an unavoidable aspect of horror — the horror of rendering a human being into raw materials, of turning death into life, of harvesting organs from an undead boy. Should a practice, however noble, be able to hold truth hostage? Perhaps the medical profession should embrace the obvious: to be an organ donor is to choose a particular way to finish our dying, at the hands of a surgeon, after some uncertain border has been crossed — a line that will change with time and circumstance, and one that science will never be able to draw with precision. — p. 41

Certainly the ethical dimensions of medical techniques deserve full exploration. It's easy to become apathetic, especially when researchers themselves seem able to determine what is allowable, which in time becomes what is acceptable. Moral considerations seldom outweigh practical benefits for ourselves or loved ones; however Sullivan, who has AIDS, concludes that

I'm not dismissing the real pain of those dying of terminal illnesses who might conceivably be saved by this research — or the pain of their families. We should indeed do all we can to end and abate any and all disease. I write as someone with a deeply vested interest in such research. But life should be measured not by how long it is lived but by how it is lived. If my life were extended one day at the expense of one other human's life itself, it would be an evil beyond measure. Some things cannot be simply bargained or rationalized away. And one of those things is surely life itself.

In judging new technologies and procedures, as a society we may knowingly embrace the utilitarian yardstick of convenience and the greatest good for the greatest number — whether that favored "number" includes all life, all mankind, or only our own particular group. Surely, though, we should individually think through what moral compromises are acceptable and what principles are inviolable, so that as a culture we will determine consciously what is vital to us and why, and act upon those conclusions together to deliberately form our future.

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